Are Ontario’s primary care models delivering on their promises?

In the last decade, efforts to improve access to primary care in Ontario have led to major changes to how family doctors practice and are paid.

A recent report suggests that these newer models of primary care are not meeting the needs of vulnerable populations, and that Community Health Centres (an older model of care) do a better job.

However, Community Health Centres are expensive, and are designed to provide more intensive services to a relatively small population.

For several decades now, a small number of family doctors have been working with other primary care providers and health promotion services in Community Health Centres (CHC). CHCs pay doctors a salary rather than fee-for-service, and are governed by community boards. CHCs were referred to as “the best kept secret in health care” in a recent Toronto Star article. However, CHCs are intended to serve a very small fraction of Ontarians.

A recent report from the Institute for Clinical Evaluative Sciences compared CHCs with other ways of delivering primary care in Ontario, such as Family Health Teams. The report suggests that CHCs are providing better care to sicker people. However, some experts caution against interpreting the results without considering the different model of care, and higher costs, of CHCs.

New models of primary care practice

In 2002 almost 10% of Ontarians lacked a primary care provider, and less than 20% of family doctors were accepting new patients. Lack of access to good primary care can lead to poor management of chronic diseases, fragmented care through walk in clinics and overburdened emergency departments. Evidence suggests that a strong primary care system results in better health.

Motivated by the lack of access to primary care, Ontario has shifted from a system where most family doctors were practicing on their own or in small groups and paid through fee for service, to group practices intended to improve the comprehensiveness and quality of care. In the past decade, more than two thirds of Ontario’s family doctors have joined these new models of care, which serve over 8 million Ontarians. Around 3 million Ontarians receive primary care from other models, or from solo family practices.

These reforms have been accompanied by substantive investments. Payments for primary care in Ontario increased by 32% from 2006 to 2010. Family doctors received $3.7 billion in payments in 2010, constituting about 1 of every 12 public dollars spent on health care in Ontario.

However, a recently released report found that patients enrolled in these newer models had higher than expected emergency department visits. Rick Glazier, a family doctor and lead researcher for this report says that Ontario has “spent a lot of money, with the main goal of improving access, and more people now have doctors, but no other measures of access [such as emergency department visits, use of walk in clinics, or same or next day access] have improved.”

One explanation for this may be that enrolled patients do not have access to after hours care through these models. While required to provide after hour care to enrolled patients according to their contracts with the Ministry of Health and Long-Term Care, a 2011 Auditor General report found that only 41% of Family Health Networks, 60% of Family Health Organizations and 74% of Family Health Groups were providing after hours services.

Community Health Centres

In contrast to some of the models introduced in the past decade, CHCs have been providing comprehensive primary care since the 1970s. Ontario’s 73 CHCs emphasize health promotion and disease prevention by providing services like counseling, cooking and home work clubs alongside primary care.

CHCs are governed by community boards which identify priority populations, such as newcomers, low-income seniors and Aboriginal Ontarians. CHCs are predominantly in urban areas and are carefully located in certain geographic settings to meet this objective. Meb Rashid, a Toronto family doctor who has practiced at a number of CHCs describes the CHC model, particularly in urban areas, as “high intensity, lower volume practices which are targeted at serving populations who are underserved, or have difficulties accessing health care services.”

The features of some of the different primary care models are summarized in the table below.

Comparing and evaluating models of primary care

The report found that CHCs are more likely to serve the most vulnerable populations – people who are more likely to be newcomers to Canada, have a high burden of mental illness and chronic diseases, and lower incomes – than other models of care. These people have tended to be more frequent users of emergency departments. However, the report found that CHC patients had considerably lower than expected rates of emergency department visits. The ratio of observed/expected emergency department visits per person was 0.79 at CHCs, compared to 1.25 at Family Health Networks, 1.06 at Family Health Organizations and 0.86 at Family Health Groups.

The report also found that the newer models of primary care – such as Family Health Teams, Family Health Organizations and Family Health Networks – tended to serve patients from higher income neighborhoods with better health status. Doctors in these models are paid a set fee per year for each patient enrolled in the practice. Rick Glazier says that these models lack the financial incentives needed to enroll higher needs patients noting that “Ontario is virtually alone in not recognizing the need to level the playing field by paying doctors more to enroll sick and disadvantaged patients in their practices.”

Are there lessons for newer models of primary care from Community Health Centres?

A spokesperson from the Ministry of Health and Long-Term Care told healthydebate.ca that there is a Ministry of Health and Ontario Medical Association working group focused on examining potential adjustments to the capitation formula. This working group discussed including other ‘complexity modifiers’, beyond age and sex, to capitation payments to family doctors.

Ontario has invested billions in an attempt to improve access to primary care. However ,there is still room for improvement, particularly around improving timely access to primary care as well as access for Ontario’s most vulnerable people.

While the CHCs show good outcomes, they are a more costly model of primary care. Patients at CHCs have longer appointment times, and the number of patients in each CHC primary care practice is significantly smaller than other family practice models in Ontario.

Glazier says that it is “costly to look after incredibly needy, disadvantaged populations in a very community focused way.” Adrianna Tetley, executive director of the Association of Ontario Health Centres says that the CHCs welcome more research on the cost effectiveness of the CHC model of primary care. Tetley urges researchers to “look beyond costs at the practice level and move to examine the use of health care system resources” such as emergency departments and prescription medications. Tetley argues that when considering system costs of CHC patients there is “an upfront investment, with money saved down the road.”

Brian Hutchison, Professor of Family Medicine at McMaster University says “this is a very complex picture and there aren’t any simple lessons to draw from this.”

What should be done to ensure models of primary care are serving patients with the highest needs?

Provide better financial incentives for doctors to enroll these patients in their practices such as capitation adjusted for socioeconomic status

Enter the debate: reply to an existing comment

9 comments

For primary care in a publicly-funded health system, there are three needs to be balanced simultaneously:

• To provide adequate capacity to assure equitable access for patients
• To improve quality of care to get the best possible outcomes for patients
• To optimize the total cost of care

The ability to monitor practice-level performance in all three dimensions would help us to better understand how to optimize that performance, and give primary care practices the feedback they need to improve. As a society, perhaps we could have a much more informed discussion on finding the right “value for money” balance.

It’s possible to measure these three dimensions; we need the ability to spread it more broadly.

We are pleased the Comparison of Models study has been profiled on your website. CHC’s effectiveness connecting services to vulnerable populations is something that needs much greater attention in the public eye.

But we are puzzled by your claims about the relative cost-effectiveness of CHCs. Let’s make arguments based on evidence, not opinion please.

The Institute for Clinical Evaluative Studies report focused on complexity of care, not cost effectiveness. And what it demonstrated is that CHCs serve people with more complex needs and do a better job than other models in keeping people out of high cost emergency departments. Not surprising. For decades health policy experts have been telling us a greater focus on the social determinants of health is what keeps people well and out of hospitals. And focusing on the social determinants of health is what exactly what CHCs do.

As health care sustainability worries build, what’s needed now is cost-effectiveness research to confirm how the CHC approach is saving money system-wide. Thus far no studies have been done. Other recent comparison of models studies indicate that, when they are, findings will be favourable. For instance, the Bruyère Research Institute has demonstrated CHCs do a better job than other models delivering promoting health and preventing and managing high cost chronic diseases.

All this adds up to the very likely conclusion CHCs are delivering a good return on investment and adding high value to the health system.

This article raises the need for accountability across the entire primary care sector. All models need to provide evidence of benefit reflecting the needs and expectations of the people of Ontario.

Benefit cannot be assessed by narrow focus on isolated indicators, it requires measurement on all aspects of comprehensive care performance including quality across all primary care services, the capacity of the practice and the costs associated with the practice (both the cost of primary care and the total health costs of the practice’s population).

Reasonable objectives for performance from any practice and model might be summarized as:

1 Assuring and imporving quality across the spectrum of all primary care services
2 Establishing sufficient capacity so that everyone has a choice of primary care practice
3 Seeking efficient methods of care delivery so that total health costs are reduced.

For over 3 years Dorval Medical has developed and implemented a model which meets these 3 objectives. Details can be found by Googling The Dorval Model.

Their struggles to provide basic access are very different from our struggles to advance equity and community health, but there are many similarities between their model and ours. We need to pursue work in Canada that investigates the effects that ripple out across the healthcare system from action or inaction in primary care. And while we’re at it how about community level action on the social determinants of health (primary healthcare)? It’s impossible to say something is expensive without knowing what it really costs!

Ultimately we need to decide what we want from primary care services, how much we are as a society willing to pay for it, and then how that service will be provided. Given that increasing taxes (the T word) seems to be anathema to any politician these days, we do not have unlimited money to spend. That means that at some point we must decide between best/optimum and acceptable. It’s a tough deciding point. However if we collectively are not willing to pay for best, just as in our day to day lives we will and must agree to accept something else.

How the current models fit into the value assessment is yet to be determined but at some point we all need to agree best is a standard that we are no longer collectively willing to pay for.

Not to belabor the point, but I think there is a good passage from the uOttawa work you cited that provides context..

In essence, CHCs are more expensive than other primary care because they tackle issues that would
have otherwise ended up within a hospital. This may make them appear expensive but at a system level they cause significant cost savings.

“Practices with higher-than-average performance on quality of care and service delivery indicators may require many more resources than practices providing a lower quality of care. Another reason is related to the limitations of the study which focused on clinical primary care; thus the collected expenditure/cost data do not take account of the costs associated with shifting health care from primary care providers onto hospitals, emergency rooms, specialists and outsourced diagnostic services, as well as the costs of prescribed drugs. The costs absorbed by patients, insurance payers, provincial governments and society as a whole are likely to be significant. If the better quality care provided by CHCs were to reduce these expenses it could diminish or eliminate the cost differences found between the CHC model and the others. Finally, it may well be that CHCs are funded are too small relative to the large fixed costs necessary to operate a multidisciplinary health centre, and hence their average costs are very high.”

This was the hardest poll I have taken on the healthydebate.ca website as I felt you pinpointed three very important solutions for primary care in Ontario. Having worked in a CHC and trained in a FHT, I can tell you I am not surprised what the report shows. CHCs have a mandate to see the most vulnerable but they also put more services under a public umbrella than are normally accessible – this means case management, counseling, prenatal classes, native healing circles, sometimes low cost dental services and more. The care provided at CHCs is more fluid, more intensive and often what is needed for patients of high needs who would otherwise fall through the cracks. Of course this care is more expensive BUT it’s also the one that has the least ED visits given the expected for its complexity of patients – the real savings are NOT in primary care, they’re in hospital care, so we should be looking at funding models that save on these downstream costs.

The capitation models in this study all had a healthier population than the Ontario average because they reimburse based on age and gender which does not take into account income (the #1 predictor of health), so I also feel that adding an SES variable in our capitation reimbursement could have a major effect on increasing equity in care service provision. And ofcourse, we must also be providing incentives (or mandating) more after hours services in our primary care models (whatever they are) as again, this will decrease the expensive costs – ER visits and also provide better continuity of care for patients.

Holistic healing techniques are showing more promise to patients even when they have lost hope in traditional medicine. How can holistic healing become part of primary care so that everyone can have access to techniques like homeopathy, naturopath, accupuncture, nutrition, yoga, chiropractor, health coaching that imparts knowledge to each person about their own body and food.

This document is provided under the terms of a CreativeCommons Attribution Non-commercial Share Alike license. The terms of the license are available at: http://creativecommons.org/licenses/by-nc-sa/3.0/. Attributions are to be made to HealthyDebate.ca, a project under the direction of Dr. Andreas Laupacis, at the Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael’s Hospital.